M-4902 (3-12)

APPLICATION/PERMIT TO EXCEED POSTED

WEIGHT OR SIZE LIMITPLEASE TYPE OR PRINT ALL INFORMATION IN bLuE OR bLAck INk www.dot.state.pa.us

PERMIT NO.

Application ishereby made by

Address ofApplicant/Owner

NAME OF APPLICANT/OWNER

STREET

PHONE

ZIP CODESTATECITY

This application is to exceed a posted (check one or both, as applicable) o Weight Limit o Size Restriction

on a (check one only) o highway o bridge; in _________________________________________________ County, PA.

The posted restriction is __________________________________________________________________________________________

and is located at or between __________________________________________ on State Route # ______________________________

This application is for _________________ of trip(s). Move begins _________________ Move ends _________________ Fee _________

(include units such as tons, feet, inches, etc.)

(also indicate on an attached map)

(number) (date) (date)

GROSS WEIGHT (Lbs.) TYPE _______________________________________________________

(Lbs.) LOAD_______________________________________________________

TOTAL LENGTH (Feet) (Inches) EQUIP./AXLES ______________________________________________

TOTAL WIDTH (Feet) (Inches) TRUCK LICENSE/ST. __________________________________________

TOTAL HEIGHT (Feet) (Inches) TRAILER LICENSE/ST. ________________________________________

Load Description

REGISTERED GROSS WEIGHT

Equipment Description/Number of Axles per Vehicle

License Number State of Registration

License Number State of Registration

Axle Number(front toback)

Axle Weight Due to Vehicle Only

(pounds)

Total Axle WeightDue to Vehicle andLoad (pounds)

Manufacturer’sRated AxleCapacity

Distance FromPrevious Axle

Width of Axle(center to centerwheel or group)

Number of Tires

PneumaticTire Width

Vehicle RegistrationNumber orVIN Number

THIS SECTION TO BE COMPLETED FOR BRIDGES ONLY

1

2

3

4

5

6

7

Totals All load-bearing wheels in a straight transverse line constitute an axle.

INSURANCE CO. NAME

EFFECTIVE PERIOD(S)

POLICY NO.(S)

PROPERTY DAMAGE$

PUBLIC LIABILITY$

I, the undersigned, hereby certify that the data submitted is correct to the best of my knowledge and belief.Signature & Title X DATE _____________________________________

INSTRUCTIONSComplete all above sections of this form and submit with a check or money order made payable to the Pennsylvania Department of Transportation, in the amount determined by the De-partment. Submit a separate application for each posted highway section (including bridges thereon), for each separately posted bridge and for each vehicle or combination. Justificationfor the permit should also be provided. Upon review of this application, the Department may approve the request by issuing the permit below.

Applicant – Do Not Write Below This Line

PERMIT TO EXCEED POSTED WEIGHT OR SIZE LIMITThe above application is approved subject to Section 4902 of the “Vehicle Code”, and all appropriate Department Regulations (in particular, 67 Pa. Code-Chapters 189, 191 or 193) and subject to any special conditions or restrictions set forth herein or attached hereto. This permit does not authorize the permitted vehicle to exceed any maximum size or weight limit.This application/permit shall be carried in the permitted vehicle while traveling upon the highway or bridge specified above (except Type 2 permits which authorize use of a particularposted highway or portion thereof by any number of over-posted-weight vehicles being driven to or from a common destination.)

Permit Issuance Date: _________________________________________________ By District Executive: _____________________________________________________________

Permit Expiration Date: _________________________________________________ For: __________________________________________________________________________Secretary of Transportation

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